Holistic sexuality encompasses more than physical sexual and reproductive function (Figure 1). The World Health Organization defines sexual health as “a state of physical, mental and social well-being in relation to sexuality.”1 Human beings are sexual from the moment of birth to the point of death; childhood is a critical time to establish a foundation of sexual self-esteem and expression, the skills to advocate for one’s own pleasure and safety, and a sense of personal sexual responsibility.2

Figure 1. The Many Facets of Sexual Health

The Role of the Parent/Caregiver

Prevention of sexual harms and promotion of positive sexual expression occurs from infancy onward. Although it can be uncomfortable for some, parents are the best primary sexuality educator for their children.2,3 Rather than having one awkward-for-everyone “talk” during puberty, discussing sex early and often reduces discomfort.2 Caregivers can incorporate discussions of sexuality as they arise naturally, addressing a wide range of topics multiple times as the child matures.4 Even open discussions of a non-sexual nature promote healthy sexual expression in youth.5 Nurturing strong attachment from infancy lays the foundation for an open, trusting relationship, which builds self-esteem and protects against sexual harms.

Prompt changing of diapers and teaching good hygiene during toileting teaches children to care for their genitals. Accurate, developmentally-appropriate information should be provided, including correct terminology for all body parts and honestly answering questions about bodily functions. Information can be provided through the lens of the family’s religious, cultural, or philosophical values, and illustrated child-friendly books can help provide information and facilitate discussion (view list of resources in Table 1, online). Developing strategies of decision-making, communication, and consent are transferrable to all facets of life, including sexual well-being.

Masturbation is a safe way for individuals of all ages and genders to learn about their bodies. In adults, masturbation reduces stress and promotes relaxation6; this is likely also true for children. It is normal and natural for infants and children to explore their own bodies, including their genitals.7 Acknowledging and celebrating pleasant sensations establishes positive expectations of pleasure. Children can be taught that touching their genitals feels good and is okay to do in private; culturally-appropriate expectations around privacy should be established without shame.

Perceptions about gender roles are developed early and greatly influence sexual expression. Low perceived sexual power – more commonly experienced by females and youth identifying as lesbian, gay, bisexual, transgender, or questioning/queer (LGBTQ) – is correlated with lack of advocacy for personal pleasure and safety.8,9 Adolescent males who hold traditional views of masculinity are more likely to engage in risky sexual activities, foster less intimacy, and engage in coercion or violence in sexual relationships.10 Modeling has an enormous impact on perceived gender roles; trusted adults of both genders can be encouraged to reflect on their communication styles, expression of affection, and self-advocacy. Conversations can be had with verbal children about their perception of gender roles; the influence of media on gender norms underscores the importance of fostering media literacy from a young age. Caregivers can foster an awareness of and respect for diversity.

Adolescence is a normal and natural time for sexual exploration and experimentation.3 The most recent Youth Risk Behavior Surveillance survey reveals that nearly half of all high school students have had sexual intercourse, while over a third are currently sexually active.11 Adolescents often engage in risky sexual behavior. Factors considered to be “risky” include earlier age at first intercourse, multiple partners, sex without a barrier, sex while under the influence of alcohol or drugs (22.1% had used alcohol or drugs before their last sexual encounter),11 and sex under conditions of coercion or violence. The consequences of these behaviors lead to serious health outcomes associated with sexually transmitted infections (STIs), early pregnancy, and increased likelihood of continuing unhealthy sexual behavior patterns.12,13

Open dialogue with parents promotes healthier sexual expression among youth, both decreasing harm and increasing pleasure.5 When parents talk to youth openly and listen non-judgmentally, youth report feeling closer to their parents and having healthier peer relationships.14 Close, communicative relationships with parents increases the likelihood that sexual activity will occur in a committed relationship, which is correlated with a more pleasurable sexual experience.5 Attributes of self-advocacy, self-esteem, and empathy are associated with orgasm, pleasure, and reciprocity in sexually-active youth, and are fostered by a strong attachment to a trusted caregiver.15 These youth display less risky sexual behavior, including delayed intercourse, reduced frequency of intercourse, decreased risk of sexual abuse and assault, reduced number of sexual partners, and increased use of condoms and other contraceptive methods.16,17

Open and approachable parenting must be balanced with appropriate monitoring and restriction of youths’ leisure activities. As with other risky behaviors, both overly-restrictive parenting and overly-lenient parenting are associated with harmful sexual behaviors. Monitoring by caregivers of youths’ free time is associated with delayed and less risky sexual behavior,5,18 including consumption of sexual content in media. As a powerful source of sexual information and influence (exposure to sexual content is correlated with earlier and riskier sexual activity),19 parental restriction and active co-viewing/listening can protect youth both through limiting exposure and communicating parental values.20,21

Youth typically begin intentionally accessing sexually-explicit media around the time of puberty; this is likely representative of normal curiosity.3 Although concern has been expressed that easy and repeated access to sexually-explicit content may lead to sexual desensitization, this has not yet been supported by the evidence.22 However, pornography dramatically affects perceptions of gender roles, sexual advocacy, pleasure, and consent, and may increase risky or coercive sexual behaviors.9,23,24 Teaching children skills of media literacy from an early age provides the skills to critically evaluate what they may encounter in pornography and other sexually-explicit media. A close relationship with a parent also enables a young person to ask questions about what they see.

Up to 28% of youth have reported engaging in sexting (“sending and sharing sexual photos online, via text messaging, and in person”),25 although it tends to occur at a higher frequency among youth who are already sexual active.3,25 While it may be a lower-physical-risk way of exploring sexual expression, sexting seems to increase the risk of engaging in other higher-risk sexual activities.25 The persistence and shareability of online and digital images can set young people (often females) up for bullying and shaming.27 Some jurisdictions consider images of adolescents shared by adolescents to be child pornography, with devastating consequences for naive perpetrators.28 Caregivers can educate youth about relevant legislation, as well as establish expectations about appropriate decision-making as soon as a young person has the opportunity to engage in social media.26

The Role of the Clinician

While delaying sexual activity reduces risk and promotes positive sexual experiences, youth must be prepared with accurate and comprehensive information in order to make healthy choices. Clinicians can be a source of information, answering children’s questions honestly and age-appropriately.29 A relaxed approach communicates the clinician’s comfort, which normalizes the topic and invites future questions. Myriad written and online resources exist for caregivers, educators, clinicians, and young people. A non-exhaustive list is provided in Table 1, online.

Sexuality-specific anticipatory guidance can be provided at all well-child checks – delivered to the caregiver in the early years, and directly to the youth as the years progress. This requires trust and rapport, best established early in the therapeutic relationship. As with all patients, an open, non-judgmental approach will encourage honesty and thus more opportunity for normalization, education, and motivational interviewing. It is normal for youth to experience curiosity and anxiety around sexual changes; they may have questions about what to expect and how to adjust their self-care. There is a strong association between pubertal changes and self-esteem,30 influenced by media and peers.3 Anticipating questions and providing guidance prior to expected changes occurring can tremendously alleviate any uncertainty or worry a young person may be experiencing. Physical examination of the entire body, including the genitals, facilitates assessment of healthy growth and development, and provides an opportunity to teach the young person about his or her body. Consent can be enabled by establishing this expectation early in the therapeutic relationship, providing education about the relevance, and by including a third party (eg, a parent or an office assistant).

A supportive and normalizing environment is of critical importance, particularly for youth who identify as LGBTQ or who are curious about exploring non-hetero/cis expressions of sexuality.31 There is a higher incidence of depression, suicidality, and substance abuse in LGBTQ youth. LGBTQ youth experience higher rates of violence, coercion and victimization, and demonstrate higher-risk sexual behavior.32 In many cases, home is not a supportive environment; a substantial number of street-involved youth identify as LGBTQ. Clinicians should screen for these concerns, and avoid hetero/cis-normative language and bias.15

Screening for engagement in sexual activity is best done with caregivers absent (caregivers and youth must be appropriately informed of the limits of confidentiality).33 It is important to discuss behaviors as opposed to definitions, since mis-education is common and sexual identity is emerging during adolescence.34 The word “sex” itself may have different meanings to different individuals, meaning penetrative intercourse to some, while overlooking the expression of sexuality through other means. Different activities carry different risks of STI transmission; accurate information must be available in order to reduce risk. Lower-risk behaviors, such as “sexting,” mutual masturbation, and oral sex are common among youth, and may be safer ways of building skills of intimacy, communication, sexual advocacy, and reciprocity.3 Youth can be encouraged to explore words like “virginity,” “abstinence,” and “sex” to frame their personal sexual expression in a way that feels pleasurable, empowering, and safe.9 Table 2 provides some language and strategies for engaging with youth.

Table 2. Strategies for Engaging with Youth Around Sexuality

Seek information in a respectful manner

“Have you been sexually active with anyone (guys, girls, or both) in the past 6 months?”

“Do you have any concerns or questions about sex?”

“What have you learned about preventing pregnancy and STIs?”

“Do you have any thoughts about birth control?”

Describe how you can help

“I can be a source of information for you, and help provide you with the resources to make healthy decisions.”

Be direct

“HIV can kill you.”

“Getting pregnant when you’re not ready can be devastating to your future.”

“Having sex while you’re drunk or high increases the risk of STIs or pregnancy.”

“Having naked pictures of your girl/boyfriend on your phone could get you in a lot of trouble with the law.”

Address limits of confidentiality

“I will keep anything you tell me confidential unless I’m worried that you or someone else might get hurt. Do you have any questions about what is and isn’t confidential?”

Set goals

“Let’s set up an appointment to talk about options for contraception.”

“Do you think you can have a conversation with your girl/boyfriend about getting tested for STIs?”

“Let’s role-play what you might do the next time you feel pressured to give a blow job.”

In one review, more than half of males admitted to wishing they had waited longer to engage in sexual intercourse; most reported feeling pressured, and more than a third reported not wanting to have had sex the first time.35 Just under 10% of high school students have reported physical violence by an intimate partner11; 8% of students have reported being physically forced to have sexual intercourse, with a higher incidence among females.11 Coercion and violence in adolescent relationships have long-lasting impacts on mental and reproductive health, including an increased risk of depression, STIs and unwanted pregnancy, and future patterns of violence.10 Adolescents should be asked about coercion or violence in casual and committed relationships.10 The age of sexual consent varies among jurisdictions; clinicians should also screen for any concerns of this nature.

Forty percent of sexually-active youth reported not having used a condom in their most recent sexual encounter; 12.9% had used no method to prevent pregnancy.11 All youth should be engaged in a discussion around appropriate contraception and prophylaxis, ideally prior to the initiation of sexual activity.36,37 Unintended teen pregnancies predict lower education, unemployment, lower lifetime earnings, single parenthood, depression, and poor infant health,38,39 while STIs contribute to both morbidity and mortality; adolescents account for half of all new STI diagnoses in the United States.40 Long-acting reversible contraceptive methods (such as intrauterine devices) are recommended as the first-line approach to prevent pregnancy,33 although youth need to know that these methods do not protect against STIs. Barrier methods should be used during all adolescent sexual encounters (in addition to any hormonal contraception) to ensure maximal protection against both STIs and pregnancy.37 Marcell et al is an excellent source for strategies to increase condom use in youth.35

Healthcare providers must be aware of STI screening and reporting guidelines in their jurisdiction. American and Canadian guidelines for screening adolescents are largely the same (more detailed guidelines42 can be found on the CDC’s website)41,42:

All adults and adolescents from ages 13 to 64 should be tested at least once for HIV

All sexually-active women younger than 25 years should be annually screened for Chlamydia and gonorrhea

All sexually-active gay, bisexual, and other males who have sex with males (MSM) should be screened at last once a year for syphilis, Chlamydia, and gonorrhea. MSM who have multiple or anonymous partners should be screened more frequently for STIs (ie, at 3 to 6-month intervals).

Anyone who has unsafe sex or shares injection drug equipment should get tested for HIV at least once a year. Sexually-active gay and bisexual males may benefit from more frequent testing (eg, every 3 to 6 months).

Summary

Young people engage in sexual activity. Optimal sexual health includes responsibility for self, reciprocity toward others, sexual efficacy, and the ability to advocate for both sexual safety and pleasure. In order to promote optimal sexual health, clinicians can encourage open, honest relationships between youth and trusted adults from infancy onward. Clinicians can be a direct source of accurate information and education, and act as a resource for caregivers in providing key messages to young people (Table 3).

Table 3. Key Messages for Children To Foster Healthy Sexuality

Sexuality is a natural and healthy part of life

You have the right to be loved and cared for, and to feel safe and protected

Your body is yours; no one else has the right to touch it or comment on it without your consent; sometimes a doctor or a nurse may need to look at or touch your body to make sure you are healthy

If you are ever uncomfortable with the way someone is looking at, touching, or talking about your body, tell an adult that you trust

Body parts should be called by their correct names

It is your responsibility to take care of your body

You have the right to have your questions and concerns about your body answered honestly and accurately

Masturbation is a natural and healthy way of exploring sexuality, delaying sexual intercourse, and learning about your body

You have the right to sexual safety, privacy, and pleasure

Others also have the right to sexual safety, privacy, and pleasure; we have the responsibility to express our sexuality in a way that is respectful of others

The only true consent is an enthusiastic one

You have the right to access confidential healthcare resources regarding sexuality, reproduction, contraception, and health

STIs lead to serious consequences and are preventable

Abstaining from sexual intercourse is the most effective way to prevent pregnancy and STIs; if you are going to engage in sexual intercourse, a barrier should be used every time

Communication and trust are key; if you can’t talk to a potential partner about having sex, you shouldn’t be having sex with that person

You are valuable and worthy, no matter whom you love or are attracted to

Young Men’s Health: “Carefully researched health information” for teenage boys and young men; produced by the Division of Adolescent and Young Adult Medicine at Boston Children’s Hospital. Includes sections for teens, parents, and practitioners.

Center for Young Women’s Health: “Carefully researched health information” for teenage girls and young women; produced by the Division of Adolescent and Young Adult Medicine at Boston Children’s Hospital. Includes sections for teens, parents, and practitioners.

Planned Parenthood: “Delivers vital reproductive health care, sex education, and information to millions of women, men, and young people worldwide.” Includes sections for teens, parents, and practitioners.

www.plannedparenthood.org

I wanna know!: “A site of the American Sexual Health Association, America’s authority for sexually transmitted infection information.” Includes sections for teens, parents, and educators.

www.Iwannaknow.org

SexualityandU: “The ultimate Canadian web site committed to providing accurate, credible and up-to-date information and education on sexual health. An initiative of the Society of Obstetricians and Gynaecologists of Canada.” Includes sections for teens, parents, and practitioners.

Answer: Sex ed, honestly: “Support for parents, practitioners, providing invaluable sexuality education resources to millions of young people and adults every year.” A division of Rutgers University. Includes sections for teens, parents, and practitioners.

Family Acceptance Project: “A research, intervention, education and policy initiative that works to prevent health and mental health risks for lesbian, gay, bisexual and transgender (LGBT) children and youth”

Leslie Solomonian, ND, is an associate professor at the Canadian College of Naturopathic Medicine, where she teaches pediatrics. Leslie also delivers holistic sexuality education programs to adults and youth. She is acutely aware of how deep and broad this topic is; she would have loved to give more attention to many themes, including sexual identity and orientation (including asexuality), the impact of media, the balance between pleasure and safety, and the complex reasons that youth engage in sexual behavior. Any omissions were difficult to make. Leslie encourages readers to view this piece as inspiration for deeper exploration and reading.

National Public Radio; Fresh Air. ‘Girls & Sex’ And The Importance Of Talking To Young Women About Pleasure. Published March 29, 2016. NPR Web site. http://www.npr.org/sections/health-shots/2016/03/29/472211301/girls-sex-and-the-importance-of-talking-to-young-women-about-pleasure. Accessed April 8, 2016.

Society for Adolescent Health and Medicine. Recommendations for promoting the health and well-being of lesbian, gay, bisexual, and transgender adolescents: A position paper of the Society for Adolescent Health and Medicine. J Adolesc Health. 2013;52(4):506-510.

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